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Turf battle

Although the high patient satisfaction rates are ideal for lobbying legislators for more authority, some nurses acknowledge that these studies may be threatening to some doctors. Georgia, for example, is the only state that does not give NPs any prescriptive authority. Myra Carmon, Ed.D., CPNP, RN, associate professor of nursing at Georgia State University and president of the Georgia Nurses Association, said the medical association in Georgia is powerful and not supportive of giving NPs more responsibility.

"We have been at the capital for many years trying to get prescriptive authority," Carmon said. "We feel like the current policy decreases access to care because it slows things down."

NPs in Georgia need to have the doctor sign off on a prescription, or the nurse calls it in under the doctor's name, Carmon said.

Jeanne Findlay, MN, CPNP, RN, who has worked as an NP for 20 years, faced similar barriers when she moved from New York to Maryland. As a nurse practitioner in New York, she could go on rounds and admit patients, but she didn't have these privileges when she moved to Maryland. This has changed in Maryland within the last three years, but doctors are slow to encourage NPs to set up their own practices, she said.

"They don't want you setting up your own shingle," Findlay said. NPs in Maryland need doctors to sign agreements stating their collaboration arrangement. She said that technically, NPs are allowed to set up their own practices if they have a written agreement with a collaborating doctor, but she said NPs would be hard-pressed to find doctors who will sign the agreement if the nurse wants to practice in a different location.

Taking the time

For Noelle Gibson, MN, CPNP, RN, the unspoken understanding between physicians and nurse practitioners is different. She works in Oregon, where NPs can set up their own practices and clinics, and there is no requirement to collaborate with a physician.

"In my experience, it's been very positive working with doctors," Gibson said. "They seem very thankful that we can spend more time with patients that need more time."

Ideally, doctors and nurse practitioners can have a symbiotic relationship, Wysocki said. NPs can see many of the patients who have more routine conditions, and this leaves doctors more time to treat patients who need a specialist.

"For the majority of things that people have, patients need somebody to teach them to take medication correctly, monitor their treatment plan or do normal health screenings," she said. "None of those things necessarily needs a specialist."

She said patients need a specialist for more complicated cases. Although this system could potentially seem to set up NPs to deal with more mundane health problems, Wysocki said this is not the case.

"For the most part, it's a highly satisfying profession," she said. "You are making independent decisions. There's just a great degree of satisfaction if a patient says 'I never understood that before.' I have had that happen. That feels really good."

Barbara Dehn, MS, NP, RN, agrees that autonomy and time to teach patients makes her job satisfying. She specializes in women's health and works with a group of doctors in Mountain View, Calif.

Dehn performs first trimester pregnancy ultrasounds, gynecologic ultrasounds and also works with infertility cases. She also does a lot of first pelvic exams for girls because these patients appreciate a health professional who can take more time for what seems like a frightening new experience.

Sometimes, doctors even refer patients to Dehn because they know she works well with sensitive patients. A doctor recently referred a patient to her who struggled with depression and suicidal thoughts. Dehn asked the patient to complete a questionnaire to determine if the woman was having panic attacks, obsessive-compulsive disorder or depression.

"After she finished the questionnaire, I just let her talk," Dehn said. "Then I asked open-ended questions." Dehn ultimately prescribed an antidepressant, suggested a therapist and asked the patient to come in for a follow-up visit three days later.

"I love working with women, and I feel like I am in that stage where I am practicing the art of nurse practitioning," she said. "The challenging thing is to recognize the fear behind the questions that come up for patients. When a patient can't verbalize the fear, I try to recognize the fear. It's seeing beyond the obvious."

Nurse practitioners are fighting for the right to use this kind of expertise in all states, and although there is still a long road ahead in certain parts of the country, Mary Knudtson, NP, a consultant for the American College of Nurse Practitioners, has hope that NPs will continue to gain ground.

"My dream would be that we are independently licensed and directly reimbursed, and that we would have an independent scope of practice," she said. "We've made tremendous progress and continue to make progress. We just need to do one thing at a time."

Contact Heather Stringer at heather_stringer@yahoo.com